A Community Mobilizes to End Medical Apartheid

Hello readers, we are pleased to announce that the peer-reviewed journal, Progress in Community Health Partnerships, has published a piece about our campaign with Bronx Health REACH to end segregation in the delivery of health care services by teaching hospitals in New York. You can download a copy of the piece here. Feedback welcome! We are using every avenue at our disposal to get the word out about this urgent issue, including the very types of publications that health care providers and policy decision-makers are likely to peruse.

Acknowledging Difference, not Defeat: A Racial Justice Perspective on the Medicaid Debate

This post, by Health Justice Director Nisha Agarwal and Staff Attorney Shena Elrington, also appears on the Race-Talk blog, Huffington Post, and Alternet.

The federal Medicaid program has become something of a policy piñata in the national discourse. Over the course of the past year conservatives have been asking, “is Medicaid real health insurance?” The public insurance program for low-income individuals has been criticized for not providing sufficient access to physicians, long wait times to see a physician when one can be accessed, and poorer quality of care once patients get in the door – all of which conservatives argue are reasons to dismantle the program altogether. If being on Medicaid isn’t much better than being uninsured, why bother spending tax dollars on it?

Meanwhile, a recent editorial in the New York Times offered unequivocal praise for the Medicaid program, pointing to a study conducted in Oregon that allowed researchers to compare the experiences of people who received Medicaid coverage to those who did not. According to the study, Medicaid recipients reported better health than the uninsured recipients  and were less likely to have medical bills sent to  collection agencies or forgo other obligations in order to pay for their medical care. Supporters of the public health insurance plan were therefore able to hit back against conservative naysayers and argue that Medicaid truly is a program worth preserving and expanding.

While the national debate lurches back and forth, we find a more complicated reality on the ground, in the low-income communities of color where we work to eliminate race- and class-based biases in the health care system. The uncomfortable truth is that Medicaid beneficiaries do often receive poorer quality of health care, particularly when it comes to accessing specialists. But to see this you have to look at how Medicaid beneficiaries fare vis-à-vis privately insured individuals, not the uninsured, which has been the focus of current debates.

For example, in  our work with Bronx Health REACH, a faith-based community coalition in the Bronx, we have seen how Medicaid patients seeking specialty services at major New York City hospitals are seen in separate—effectively segregated—facilities from their privately-insured peers, with longer wait times, less experienced doctors, and much less continuity and coordination of care. (You can read more about these problems in this monograph published by the Bronx Health REACH coalition and in this complaint we filed with the New York State Attorney General.)

Working with low-income parents, we have also seen how children with Medicaid have to wait for grotesquely long periods of time before they can get mental health treatment and special education evaluations, if they are able to access these services at all, and how elite institutions providing such services refuse to serve publicly insured populations despite the significant shortage of pediatric mental health providers in New York City.

Our experience thus seems to support conservative arguments to some extent: Medicaid beneficiaries do not have sufficient access to physicians, experience long wait times to see a physician when one can be accessed, and suffer from poor quality of care once they get in the doctor’s door, at least when compared with those patients who are privately insured.

Undoubtedly the current climate surrounding Medicaid makes it difficult for advocates to point out the lower quality of care Medicaid beneficiaries receive, for fear that any criticism of the program will serve as powerful ammunition for the other side to use. But acknowledging certain aspects of the conservative argument need not mean that advocates have to accept the entirety of their conclusions. Something else we’ve learned through our work is that Medicaid isn’t “bad” insurance per se. Rather, healthcare providers and institutions choose to treat Medicaid beneficiaries badly by discriminating against them with respect to the quality of care provided. Consider the Bronx example. Hospitals in New York City (and elsewhere) are not only reimbursed by Medicaid for providing patient care, they also receive over $1 billion through the Medicaid program for non-patient purposes such as resident doctor training – a funding stream so substantial that the New York hospital industry is fighting tooth and nail to keep it safe from federal budget cuts. Medicaid seems to pay hospitals very well, and yet these same hospitals choose to provide segregated and unequal care to Medicaid beneficiaries. Why?

As with many things, these bizarre dynamics cannot be understood without accounting for race, and for the fact that the vast majority of publicly insured individuals in New York City are black and brown. We have heard how top-flight specialists want to be able to choose the patients that they treat, which is invariably code for avoiding people of color who are perceived to be more “complicated” and “non-compliant.” Elite NYC hospitals eager to attract these specialists happily comply to doctors’ demands by giving them fancy facilities to see their preferred patients, while the Medicaid patients are separated out into “clinics”, where they are treated by a rotating band of doctors-in-training.

In addition to wanting to attract renowned specialists, the hospitals want to attract the “right” kind of patients – that is, wealthy, white, suburban patients. Behind closed doors administrators will openly argue that their “‘paying’ patients will not want to sit in the same waiting room as people on Medicaid,” so it is simply better for the hospital to segregate the two groups.

Worse still, these biases become a part of the culture of how medicine is taught, with students and residents working with Medicaid patients in the clinics learning very early on that some patients—the kinds of patients they get to practice on, the poor patients of color—are less worthy than others. Indeed, research has suggested that by the end of their medical education, student doctors actually become more biased than they were when they began medical school. These biases, whether conscious or not, permeate the medical system at both an individual and systemic level, affecting the quality of care that Medicaid beneficiaries receive.

From our perspective, the debate about Medicaid is less about left-and-right and more about black and white. The conservatives’ sleight of hand is to point to quality of care problems for Medicaid beneficiaries and to jump from there to the conclusion that the Medicaid program is to blame, which obscures the mediating role that institutional racism plays in ensuring poor outcomes for Medicaid patients. Meanwhile, supporters of Medicaid effectively erase race from the debate as well by closing their eyes to the many challenges Medicaid beneficiaries face in accessing high-quality health care, despite the fact that they are walking in the door with an insurance that research shows is pretty good. A more nuanced position would acknowledge differences in care without accepting defeat. It is not the Medicaid program that must be dismantled, but the biased attitudes and policies that lead Medicaid patients to get inferior quality of care.

Making Separate and Unequal Illegal

For those of you who’ve been following our campaign to eliminate separate and unequal health care delivery in New York City’s academic medical centers, we’ve got some good news!  This morning legislation was introduced in the New York State Senate that would make it explicitly clear that private academic medical centers in New York City must provide care to all patients in the same place at the same time.  In other words, they are not allowed to steer Medicaid patients to one section of the hospital, where they provide them with lesser quality of care from privately insured patients, who are seen in another part of the hospital.  To read the text of the bill, click here.  A clearer summary of and justification for the legislation can be viewed here, in what is called the “sponsor memo.”  We will keep you posted as this campaign progresses!

Run On and See Where It Ends: Fighting to Make Health Equality a Reality

This post, by Health Justice Director Nisha Agarwal, has also appeared on Race-Talk, Huffington Post and AlterNet.

Saturday morning, April 17^th, the auditorium of Junior High School 22 in the Bronx was crowded with community residents who had gathered for a town hall meeting. Health care reform had passed, but these folks knew that their problems were not over. Ensuring that most Americans have health insurance, while important, will not be enough to eliminate the racial and ethnic disparities that have been dyed deep into the U.S. healthcare system and that reveal themselves, vividly, in the Bronx.

To save black and brown lives and to improve the vibrancy of those lives requires looking beyond access and focusing on quality. It requires, among other things, an examination of the practices of major health care institutions, which deny low-income people of color the highest quality of care they have to offer even when those people have health insurance.

The specific issue that community members had gathered about is this: in New York City, prominent private hospitals–facilities like New York-Presbyterian, Montefiore Medical Center, Mount Sinai–operate two different systems of care for patients with the same kinds of health problems but with different types of insurance. There are, for example, cardiology “clinics” for patients with Medicaid, a public insurance program, and there are cardiology “faculty practices” for patients with private insurance. Sometimes the clinics are right next door to the faculty practices, but Medicaid patients won’t be allowed into the faculty practices, and privately insured patients are not sent to the clinics.

What is more, the hospitals allow valuable and finite resources to be allocated unequally between the two systems of care. For instance, clinics often do not have enough financial support from the hospital to perform basic care coordination tasks like sending notes back to the patient’s primary care physicians, while faculty practices often receive administrative and other forms of support so that such tasks are routinely able to be done.

More significantly, board certified faculty physicians, the top docs, spend only a fraction of their time in the clinics–a mere half a day a week for four months out of the year in one case–even though they are required by law to spend the bulk of their time supervising resident doctors and caring for patients in the clinic setting instead of in the faculty practice. Hospitals do nothing to shift the balance and, as a result, Medicaid patients do not have a single, board-certified physician who is ultimately responsible for their care, whereas privately insured patients do. Here is a chart summarizing some of the main inequalities:

The impact of these differences are felt on the bodies and backs of low-income patients. At the town hall meeting, Medicaid beneficiaries spoke of being bounced from one doctor-in-training to the next within a fragmented clinic system, where fingers and toes were almost amputated and cancer remained undiagnosed until dangerously late. And they spoke of how these outcomes were not race neutral. In New York, people of color are far more likely to have public insurance than whites, which means that when hospitals create two systems of care based on insurance they are also perpetuating a de facto segregation based on race. (For more background and helpful stats on this issue, please see this excellent monograph on medical apartheid in New York City by the Bronx Health REACH coalition, the group that first brought this problem to light.)

Representatives of health care institutions have argued publicly that community residents are missing the point. The source of the problem, they claim, is with the Medicaid program and not with the hospitals. Doctors’ offices are reimbursed at extremely low rates through Medicaid and therefore can’t afford to see publicly insured patients in their faculty practices. The clinics have been set up to provide an avenue for care that otherwise wouldn’t exist.

But it is the hospital representatives who are missing the point. The provision of care to Medicaid patients is not something hospitals are choosing to do out of the goodness of their hearts. Under federal law, hospitals are required to open their doors to Medicaid beneficiaries, and provide them care without discrimination, in exchange for accepting millions of dollars of government funding to modernize and upgrade their facilities.

Moreover, while Medicaid reimbursement rates for doctors’ offices are very low, they are much higher for clinic-based services. In order to integrate care, hospitals could simply shift their resources to the clinic and ensure that all patients, public and private alike, are seen in that setting, instead of siphoning off the privately insured patients to the faculty practices. The increased resources and mixed patient population would help ensure that the quality of clinic care would improve dramatically and that this high-quality care would be accessible to all on equal terms.

Of course, hospitals are choosing not to do this and, given the dubiousness of the financial arguments, one is left to presume that their motives are more suspect: one cannot attract wealthy, white patients from the Upper East Side and Westchester if those individuals will have to sit in the same waiting room as people of a different class or race. The fight to integrate our health care system and to reduce racial and ethnic health disparities is therefore going to be just as messy as the historic battles to integrate our educational system or our housing. But fight is what Bronx residents will do, even in the face of uncertainty and resistance. As one faith leader said at the town hall meeting, quoting a song from the civil rights movement of deep South, we must “run on and see where it ends.”

To learn more about Bronx residents’ efforts to eliminated segregation in New York City’s healthcare system, please click here or visit the website of Bronx Health REACH.

Hospital Mismanagement and the Perpetuation of Racial and Ethnic Disparities

This post, by the Director of NYLPI’s Health Justice Program, originally appeared on the blog of the Committee of Interns & Residents, which is fighting for the right to unionize at St. Barnabas Hospital.  You can read more about CIR’s efforts here.

Last summer, on her wedding night, Juana R. arrived at the St. Barnabas Hospital emergency department with severe abdominal pain.  A Spanish-speaker, Ms. R. needed an interpreter to communicate effectively with her providers, but she was never given one.  Instead, from the moment of her arrival at the ED, to her transfer to the ICU, to her eventual discharge a month later, she was systematically silenced by the hospital.  Invasive tests and procedures were performed without obtaining Ms. R.’s consent (she signed a litany of documents in English only).  Various medication regimens were attempted, many of which caused extreme pain and nausea, but Ms. R had no way of properly communicating these problems to her providers.  Only after legal intervention did this patient receive the communication assistance services she needed in order to understand her diagnosis and the reason for her admission.  Now, over a year after her discharge from Barnabas, Ms. R. remains emphatic that she will never again return to the hospital for care. She describes what she endured as a nightmare. [1]

As previously reported on this blog, Ms. R.’s case resulted in St. Barnabas Hospital being cited by the State Department of Health for failure to comply with public health regulations.  More broadly, her experience speaks to the ways in which poor hospital administration can compromise patient care and exacerbate racial and ethnic disparities in health care.

Well-known studies about the relationship between race and health care have focused on the individual patient-provider interaction – on how inter-personal biases and prejudices can sway treatment decisions.  However, in my experience as a civil rights lawyer in this field, I have found that institutional racism is a more salient factor than individual animus in explaining my clients’ negative encounters with the health care system.  Patients like Ms. R. are denied the interpretation services to which they are entitled not because of the ill will of particular caregivers, but because, more typically, hospitals like Barnabas are not managed well enough to have the policies and practices in place to ensure timely access to important support services – a systems failure that hurts patients and providers.

My office has also found that, across the city, health care institutions will steer Medicaid and uninsured patients, who are disproportionately people of color, into poorly equipped and under-staffed clinic settings while “better” patients (i.e. white, privately insured patients) are sent to the faculty practices.  At the broadest level, this upward redistribution of health care resources has meant that hospitals located in New York City’s low-income communities of color have closed down over the past decade, while facilities located in more affluent white communities have thrived.  In some cases, the hospitals that shut their doors had patient populations that were over 90% African-American, Latino and Asian.

Viewed in this way, the primary way to eliminate racial and ethnic disparities in health care is to overhaul the institutions that create and perpetuate racial and economic disparities within medicine.  This means more people like Ms. R. stepping forward and demanding investigations of unlawful practices at hospitals like St. Barnabas.  It also means more communities raising their voices against hospital policies that enrich some while impoverishing others.  Ultimately, it means more of us—all of us—speaking out against health care institutions designed to promote private gain over the public’s health.

State Cites St. Barnabas for Failure to Provide Language Services

This post, about our successful efforts to secure and enforce rights to language services for a client at St. Barnabas Hospital in the Bronx, originally appeared on the blog of the Committee of Interns & Residents, which is fighting for the right to unionize at St. Barnabas Hospital.

The NY State Department of Health recently issued a citation to St. Barnabas finding that the hospital has violated state laws mandating that non-English speaking patients receive translation services so that they can understand diagnoses, treatment plans, and other essential healthcare information.

According to the attorney who prepared the complaint, a Spanish-speaking patient admitted to St. Barnabas Hospital filed a complaint with the State after spending more than a week in the hospital without receiving translation services that would allow her to understand her diagnosis and medical documents she was asked to sign. Only after the patient’s attorney intervened did St. Barnabas provide a telephone-based translation service to the patient.

The Department of Health’s investigation finds the following violations of state law:

• St. Barnabas failed to document the patient’s language preference.
• St. Barnabas failed to document whether the patient was provided with a qualified translator.
• After the patient was diagnosed with tuberculosis, St. Barnabas failed to document that the diagnoses and treatment plan were explained to the patient in a language she could understand.

In diverse communities like the Bronx, where it is estimated that more than 50% of families speak a  language other than English at home, timely access to effective translation services is essential to delivering quality healthcare.

Research compiled by the Agency for Healthcare Research and Quality finds that “Language barriers in the health care setting can lead to problems such as delay or denial of services, issues with medication management, and underutilization of preventive services.”  Local stories compiled by New York Lawyers for the Public Interest also illustrate the severe consequences of inadequate communication in healthcare settings.

Given these high stakes, let’s hope that this Bronx patient’s complaint has spurred St. Barnabas Hospital to make real improvements in the language services it provides to the communities it serves.

CNN News Story: Medical Care Double Standard?

Last night, CNN featured our campaign with Bronx Health REACH on separate and unequal care in New York City academic medical centers.  You can view it here.

It is unusual for mainstream media to tackle problems such as institutional racism in the health care system, and for that reason alone it was exciting for our campaign to get the kind of exposure that it did last night.  This was not merely a situation of “any press is good press,” either.  From our point of view, CNN’s coverage was sensitive, thoughtful and true to what we have heard in the community when the cameras are not running.

But the reaction to the story outside our community–outside the Bronx, outside the civil rights & racial justice community–has been far less approving.  The general tenor of the commentary by the CNN viewing public is that blacks should stop complaining because whites get bad care too.  This is tragic because it is partly true.  White people absolutely do get bad care within the American health care system, particularly if they are not wealthy or are uninsured.  In fact, one of the claims in our case is based on a federal law that, among other things, makes it unlawful for hospitals to discriminate against patients because they are on public health insurance.

However, it does not follow from this that blacks and Latinos should stop complaining about the inferior care that they systematically receive within the system.  No, the truth is we should all be complaining loudly and constantly about the failures of the existing health care system.  People of color are disproportionately and profoundly more likely to get the short end of the health care stick, and so we should be raising our voices and demanding change with all the energy we can muster.  But all of those white people who wrote on CNN’s blog, sharing their personal stories of pain within the health care system, should speak out too — not in opposition, but in solidarity.  Otherwise, the whirling maelstrom that is the American health care system will sink all our boats.

For a similar view, please check out this post by Dr. Neil Calman, one of the founders of Bronx Health REACH and the physician featured in the CNN news story.

CNN features Bronx Community’s Civil Rights Campaign

For the past two years, we have been representing a community coalition in the Bronx in a case about insurance- and race-based segregation in New York City hospitals.  This Monday night, our campaign is going to be featured in an investigative news piece by Dr. Sanjay Gupta on CNN!  The piece will air during the Anderson Cooper 360, between 10pm and midnight; not sure yet which hour.  Please tune in and show your support!  (Or for those of you with more new-fangled technology, be sure to DVR it.)

Better yet, tune in with a group and use the story as an opportunity to talk about institutional racism in the health care system, and what can be done about it.  Check out our Community Discussion Guide to help you facilitate the conversation.  If you’re a health care provider, you get your own Provider Discussion Guide.

And please spread the word.  There’s been a lot of talk about the health reform proposals coming out of Washington these days.  Well, we’re offering a plan rooted in community activism, South Bronx style.